Does it make sense to take a 33-year-old female patient with untreated Attention Deficit Hyperactivity Disorder (ADHD) and post-concussion syndrome, currently on Qelbree (viloxazine), Wellbutrin XL (bupropion), and Prozac (fluoxetine), off work for a comprehensive, multidisciplinary treatment approach due to significant symptoms impacting her work performance?

Should This Patient Be Taken Off Work for Comprehensive Treatment?

Yes, temporary work leave is warranted for this 33-year-old patient to engage in intensive multidisciplinary rehabilitation, as her post-concussion syndrome symptoms are severe enough to cause workplace performance issues, and guidelines strongly recommend coordinated interdisciplinary treatment when symptoms persist beyond 4 weeks or significantly impair function. 1, 2

Rationale for Work Leave

Severity Threshold Met

• This patient's symptoms are causing documented work impairment (written up at work), which indicates her functional capacity is compromised beyond what can be managed with workplace accommodations alone 3
• Post-concussion syndrome affecting work performance at this stage (with untreated ADHD as a comorbidity) represents the 15-20% of patients who develop persistent symptoms requiring intensive intervention 1
• The American Heart Association/American Stroke Association recognizes that cognitive impairments are a primary deterrent to returning to work or maintaining employment, and that return to work may be facilitated by cognitive or vocational rehabilitation 3

Treatment Intensity Requirements

• Interdisciplinary coordinated rehabilitation requires treatment from at least two different healthcare disciplines, administered minimally once weekly for 4 weeks, which is difficult to accomplish while maintaining full-time work 1
• The comprehensive approach needed includes graded physical exercise, vestibular rehabilitation (if indicated), psychological treatment (at least 1 hour weekly for minimum 4 weeks), and potentially oculomotor vision treatment 1, 2
• Each intervention component requires dedicated time and energy that competes with work demands, and attempting both simultaneously may compromise treatment efficacy 1

Critical Treatment Components Requiring Time Off

Physical and Vestibular Rehabilitation

• Sub-symptom threshold aerobic exercise with gradual increases in intensity requires careful monitoring and adjustment, which is incompatible with the cognitive and physical demands of full-time work 1, 2
• If vestibular dysfunction is present, rehabilitation including habituation exercises, adaptation exercises, and balance training must be performed at least once weekly for minimum 4 weeks 1, 2

Psychological Treatment for ADHD and Post-Concussion Symptoms

• Individual or group therapy should be administered at least 1 hour weekly for minimum 4 weeks, showing positive effects on overall symptom burden, emotional symptoms, and quality of life 1
• Her untreated ADHD represents a significant comorbidity that compounds her post-concussion cognitive difficulties and requires dedicated attention 3
• The combination of anxiety and sleep disturbances (common in both ADHD and post-concussion syndrome) requires cognitive behavioral therapy as first-line treatment 1

Medication Optimization Concerns

• Her current medication regimen (Qelbree, Wellbutrin XL, Prozac) requires careful monitoring during this critical treatment phase 4
• Qelbree can cause somnolence (16% in pediatric trials, 6% in adults) and fatigue (6% in pediatric trials, 12% in adults), which may be contributing to her work performance issues 4
• The FDA label specifically warns that "patients should not perform activities requiring mental alertness, such as operating a motor vehicle or operating hazardous machinery until they know how they will be affected by Qelbree" 4
• This medication adjustment period alone justifies temporary work leave while assessing her response and tolerability 4

Avoiding Critical Pitfalls

Do Not Delay Active Management

• The Ontario Neurotrauma Foundation recommends that active management at 2 weeks can prevent progression to persistent post-concussion syndrome—waiting for spontaneous recovery while she continues to struggle at work is contraindicated 2
• Complete rest beyond the first 24-48 hours should be avoided, but this does not mean continuing full-time work; rather, it means engaging in structured, graded rehabilitation activities 2

Do Not Underestimate Recovery Time Needs

• Problems may persist for at least 6 months and may require not only continued medical care but also social assistance with employment issues during recovery 2
• The evidence shows that 15-20% of concussion patients develop persistent symptoms, and this patient clearly falls into that category given her ongoing work impairment 1

Structured Return-to-Work Plan

During Leave Period (Minimum 4-8 Weeks)

• Implement coordinated treatment from at least two healthcare disciplines (psychology, physical therapy, and potentially occupational therapy for cognitive rehabilitation) 1, 2
• Gradually increase duration and intensity of cognitive activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms 2
• Continue monitoring collaboratively with patient to determine what modifications are needed to maintain activities without significantly exacerbating symptoms 2

Gradual Work Reintegration

• Once symptom burden improves with multidisciplinary treatment, implement a phased return-to-work schedule starting with reduced hours 3, 2
• Coordinate with employer for workplace accommodations during transition period 3
• Continue therapeutic interventions during gradual work reintegration to maintain treatment gains 1

Evidence Quality Considerations

• The recommendations for interdisciplinary coordinated rehabilitation are based on low to moderate certainty evidence but represent consistent consensus across multiple guidelines 1, 2
• The specific context of work impairment as an indication for intensive treatment is supported by stroke rehabilitation literature, which demonstrates that cognitive impairments significantly impact return to work and employment maintenance 3